Parkinson Disease

 

Am Fam Physician. 2020 Dec 1;102(11):679-691.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/parkinsons-disease/.

Parkinson disease is a progressive neurodegenerative disorder with significant morbidity and mortality. Most patients consult with their primary care physician about Parkinson disease symptoms before seeking care from a specialist. The diagnosis of Parkinson disease is clinical, and key disease features are bradykinesia, rigidity, and tremor. The main diagnostic signs of Parkinson disease are motor symptoms; however, Parkinson disease is also associated with nonmotor symptoms, including autonomic dysfunction, depression, and hallucinations, which can make the initial diagnosis of Parkinson disease difficult. Disease progression is variable and clinical signs cannot be used to predict progression accurately. Therapies, including levodopa, have not demonstrated the ability to slow disease progression. Motor symptoms are managed with carbidopa/levodopa, monoamine oxidase-B inhibitors, and nonergot dopamine agonists. Prolonged use and higher doses of levodopa result in dyskinesias and motor symptom fluctuations over time. Deep brain stimulation surgery is performed for patients who do not achieve adequate control with levodopa therapy. Deep brain stimulation is most effective for significant motor fluctuations, dyskinesias, and tremors. Nonmotor symptom therapies target patient-specific conditions during the disease course. Interdisciplinary team care can alleviate multiple symptoms of Parkinson disease.

Parkinson disease is a progressive neurodegenerative disorder with significant morbidity and mortality. Approximately 60,000 people are diagnosed with Parkinson disease each year in the United States; it is the 14th leading cause of death, with most patients dying from complications of the disease.1 Most patients consult with their primary care physician about Parkinson disease symptoms before seeking care from a specialist. Primary care physicians are often the most accessible to patients and caregivers coping with this disease.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Carbidopa/levodopa (Sinemet, Rytary), nonergot dopamine agonists, and monoamine oxidase-B inhibitors should be used for initial treatment of Parkinson disease.1012

A

Several randomized controlled trials that evaluate use of each agent or class for motor symptom management early in the disease

Dopamine agonists, catechol O-methyltransferase inhibitors, or monoamine oxidase-B inhibitors should be added to carbidopa/levodopa therapy to treat motor symptoms of advanced Parkinson disease.13,14,20

A

Several randomized controlled trials that evaluate the addition of each agent or class; there are no head-to-head trials comparing the effectiveness of adding one agent vs. another

Amantadine should be considered for treatment of dyskinesias in patients with advanced Parkinson disease.1012

B

Observational and randomized controlled trials with limited and inconsistent data

Nonmotor symptoms of Parkinson disease should be reviewed and addressed at each visit.24

C

Expert opinion

Physicians should consider referring patients with Parkinson disease to an interprofessional team to improve motor symptoms, mood, and quality of life.30

B

One small randomized controlled trial showing improved outcomes in motor symptoms, mood, and quality of life with interprofessional care vs. the control group (i.e., care by a neurologist only)


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Carbidopa/levodopa (Sinemet, Rytary), nonergot dopamine agonists, and monoamine oxidase-B inhibitors should be used for initial treatment of Parkinson disease.1012

A

Several randomized controlled trials that evaluate use of each agent or class for motor symptom management early in the disease

Dopamine agonists, catechol O-methyltransferase inhibitors, or monoamine oxidase-B inhibitors should be added to carbidopa/levodopa therapy to treat motor symptoms of advanced Parkinson disease.13,14,20

A

Several randomized controlled trials that evaluate the addition of each agent or class; there are no head-to-head trials comparing the effectiveness of adding one agent vs. another

Amantadine should be considered for treatment of dyskinesias in patients with advanced Parkinson disease.1012

B

Observational and randomized controlled trials with limited and inconsistent data

Nonmotor symptoms of Parkinson disease should be reviewed and addressed at each visit.24

C

Expert opinion

Physicians should consider referring patients with Parkinson disease to an interprofessional team to improve motor symptoms, mood, and quality of life.30

B

One small randomized

The Authors

show all author info

ANNE D. HALLI-TIERNEY, MD, is the director of the geriatrics fellowship and an assistant professor in the Department of Family, Internal, and Rural Medicine at the University of Alabama, Tuscaloosa....

JACQUELYNN LUKER, MD, is an assistant professor in the Department of Family, Internal, and Rural Medicine at the University of Alabama.

DANA G. CARROLL, PharmD, BCGP, is a clinical professor at Auburn (Ala.) University Harrison School of Pharmacy and is an adjunct faculty member in the Department of Family, Internal, and Rural Medicine at the University of Alabama.

Address correspondence to Dana G. Carroll, PharmD, University of Alabama, Northeast Medical Building, Box 244047, 211 Peter Bryce Blvd., Tuscaloosa, AL 35487 (email: dcarroll1@ua.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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